Nokea
One bed is available on the eating disorders unit. Which patient should be admitted? The patient whose assessment findings show the weight dropped from:
- A. 150 to 102 pounds over a 4-month period.
- B. 120 to 90 pounds over a 3-month period.
- C. 130 to 100 pounds over a 2-month period.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the patient has experienced a significant weight drop from 150 to 102 pounds over a 4-month period. This represents a loss of 48 pounds over a relatively longer period, indicating a more severe and prolonged issue with weight loss. The other choices show weight drops of 30 pounds over 3 months (B) and 30 pounds over 2 months (C), which are also concerning but not as severe or long-lasting as the situation described in choice A. Choice D is incorrect as at least one patient should be admitted based on the information provided.
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An outpatient diagnosed with schizophrenia tells the nurse, I am here to save the world. I threw away the pills because they make God go away. The nurse identifies the patients reason for medication nonadherence as:
- A. poor alliance with clinicians.
- B. inadequate discharge planning.
- C. dislike of medication side effects.
- D. lack of insight associated with the illness.
Correct Answer: D
Rationale: The patient's belief in an exalted role and rejection of medication due to hallucinations (God's voice) reflect lack of insight (D) into their illness, the primary reason for nonadherence here.
An older adult patient was diagnosed with schizophrenia at age 18. A nurse at the outpatient medication clinic interviews this patient. Which communication strategy will be most helpful?
- A. Ask questions that can be answered with yes or no.
- B. Ask clear, simple questions using concrete language.
- C. Use silence often and let the patient take the lead.
- D. Use open-ended, indirect questions.
Correct Answer: B
Rationale: Communication with individuals who have schizophrenia might be difficult because of their various thought disorders. The nurse can be most effective by using simple language, keeping to concrete concepts, and clarifying and validating as needed (B). Yes/no questions (A) limit information, silence (C) may not engage, and open-ended questions (D) may confuse.
A patient asks, 'What advantage does a durable power of attorney for health care have over a living will?' The nurse should reply, 'A durable power of attorney for health care:
- A. gives your agent authority to make decisions during any illness if you are incapacitated
- B. can be given only to a relative, usually the next of kin, who has your best interests at heart
- C. can be used only if you have a terminal illness and become incapacitated
- D. cannot be implemented until 30 days after the documents are signed
Correct Answer: A
Rationale: A durable power of attorney for health care is an instrument that appoints a person other than a health care provider to act as an individuals agent in the event that he or she is unable to make medical decisions. No waiting period is required for it to become effective, and the individual does not have to be terminally ill or incompetent for the person appointed to act on the individuals behalf.
A patient diagnosed with schizophrenia tells the community mental health nurse, 'I threw away my pills because they interfere with Gods voice.' The nurse identifies the etiology of the patients ineffective management of the medication regime as:
- A. inadequate discharge planning
- B. poor therapeutic alliance with clinicians
- C. dislike of antipsychotic medication side effects
- D. impaired reasoning secondary to the schizophrenia
Correct Answer: D
Rationale: The patients ineffective management of the medication regime is most closely related to impaired reasoning. The patient believes in being an exalted personage who hears Gods voice, rather than an individual with a serious mental disorder who needs medication to control symptoms. Data do not suggest any of the other factors often related to medication nonadherence.
A client with a borderline personality disorder tells the nurse, 'My doctor tells me there's something wrong with the hard wiring of my brain, and that's why I'm so impulsive and get so many mood swings. He said he's going to prescribe some medication.' Being aware of current practice guidelines, the nurse will prepare a teaching plan for:
- A. Lithium
- B. Fluoxetine
- C. Lorazepam
- D. Haloperidol
Correct Answer: B
Rationale: The correct answer is B: Fluoxetine. Borderline personality disorder (BPD) is primarily treated with psychotherapy, but in some cases, medication is used to manage symptoms like impulsivity and mood swings. Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), is commonly used to address mood instability and impulsivity in BPD. SSRIs help regulate serotonin levels in the brain, which can improve mood stability and decrease impulsive behaviors. Lithium (choice A) is used for bipolar disorder, not BPD. Lorazepam (choice C) is a benzodiazepine used for anxiety and not typically recommended for BPD. Haloperidol (choice D) is an antipsychotic used for conditions like schizophrenia and not typically indicated for BPD.